Journal of
Clinical Medicine
Review
Non-Invasive Continuous Measurement of Haemodynamic
Parameters—Clinical Utility
Aleksandra Bodys-Pełka 1,2 , Maciej Kusztal 1 , Maria Boszko 1 , Renata Główczyńska 1, *
and Marcin Grabowski 1






Citation: Bodys-Pełka, A.; Kusztal,
M.; Boszko, M.; Główczyńska, R.;
Grabowski, M. Non-Invasive
Continuous Measurement of
Haemodynamic Parameters—Clinical
Utility. J. Clin. Med. 2021, 10, 4929.
https://doi.org/10.3390/jcm10214929
Academic Editor: Tatsuo Shimosawa
Received: 12 September 2021
Accepted: 20 October 2021
Published: 25 October 2021
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Attribution (CC BY) license (https://
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4.0/).
J. Clin. Med. 2021, 10, 4929. https://doi.org/10.3390/jcm10214929
1 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland;
aleksandra.bodys1@gmail.com (A.B.-P.); maciekrm@gmail.com (M.K.); mariaboszko@gmail.com (M.B.);
marcin.grabowski@wum.edu.pl (M.G.)
2 Doctoral School, Medical University of Warsaw, 02-091 Warsaw, Poland
* Correspondence: renata.glowczynska@wum.edu.pl; Tel.: +48-5992-616
Abstract: The evaluation and monitoring of patients’ haemodynamic parameters are essential in
everyday clinical practice. The application of continuous, non-invasive measurement methods is a
relatively recent solution. CNAP, ClearSight and many other technologies have been introduced to
the market. The use of these techniques for assessing patient eligibility before cardiac procedures,
as well as for intraoperative monitoring is currently being widely investigated. Their numerous
advantages, including the simplicity of application, time- and cost-effectiveness, and the limited risk
of infection, could enforce their further development and potential utility. However, some limitations
and contradictions should also be discussed. The aim of this paper is to briefly describe the new
findings, give practical examples of the clinical utility of these methods, compare them with invasive
techniques, and review the literature on this subject.
Keywords: blood pressure wave analysis; continuous non-invasive measurement of haemodynamic
parameters; cardiac output
1. Introduction
Recently, there has been a rapid development in non-invasive, haemodynamic mon-
itoring technologies. As more and more devices enter the market, the availability of the
new approach develops. Despite being often described as the ‘gold standard’, invasive
methods can be associated with more complex procedures and the risk of complications,
including infection. Therefore, the search for other solutions is necessary. The monitoring
of haemodynamic parameters, especially cardiac output, is an essential element of clinical
practice. Haemodynamics monitoring can be divided into three groups: invasive methods
(requiring the insertion of a specific catheter, as well as direct cardiac and vascular access),
less invasive methods (requiring arterial and venous access) and non-invasive methods
(without disrupting a patient’s skin and tissues) [1].
This paper aims to analyse the commonly used techniques of haemodynamic parameters’
measurements and to describe the possibilities of currently available non-invasive methods.
2. Invasive Methods—The Gold Standard
The accuracy of the non-invasive haemodynamic parameters’ measurements and their
comparison to values obtained by the invasive methods, is crucial in clinical practice.
The most invasive, as well as the most precise, technique of haemodynamic parameters’
measurements is pulmonary artery catheterisation (PAC), using the Swan-Ganz catheter.
It is inserted via the subclavian or internal jugular vein access and sequentially passes
through the venous system into the right atrium of the right ventricle. Next, it is placed in
the distal part of the pulmonary artery’s branch. At this location direct measurements can
be made, including the cardiac output (CO), central venous pressure (CVP), right atrial and
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be made, including the cardiac output (CO), central venous pressure (CVP), right atrial 
and  ventricular  pressure,  pulmonary  artery  pressure  and  pulmonary  capillary  wedge 
ventricular pressure, pulmonary artery pressure and pulmonary capillary wedge pressure
pressure (PCWP). The cardiac output is assessed using the thermodilution technique. A 
(PCWP). The cardiac output is assessed using the thermodilution technique. A cold saline
cold saline solution of a known volume and temperature is injected into the right atrium. 
solution of a known volume and temperature is injected into the right atrium. Passing
Passing through the ventricle and into the pulmonary artery, the injectate mixes with the 
through the ventricle and into the pulmonary artery, the injectate mixes with the blood,
blood, cooling it. Then, a thermistor located at the catheter’s tip measures the blood tem‐
cooling it. Then, a thermistor located at the catheter’s tip measures the blood temperature.
perature. Taking into account the temperature and volume of the saline solution, as well 
Taking into account the temperature and volume of the saline solution, as well as the
as the quantified change in blood temperature, a computer determines the thermodilution 
quantified change in blood temperature, a computer determines the thermodilution profile
profile and calculates the right ventricular cardiac output. The procedure is often repeated 
and calculates the right ventricular cardiac output. The procedure is often repeated and
and the measurement is averaged. Additionally, PAC enables the indirect measurements 
the measurement is averaged. Additionally, PAC enables the indirect measurements of
of  many 
many other 
other haemodynamic 
haemodynamic parameters 
parameters suchsuch  as  systemic 
as systemic vascular 
vascular resistance 
resistance (SVR),(SVR), 
stroke
stroke  index  (SI),  pulmonary  vascular  resistance  (Figure  1).  Another  advantage 
index (SI), pulmonary vascular resistance (Figure 1). Another advantage worth mentioning worth 
mentioning is the opportunity of obtaining mixed venous oxygen saturation (SvO
is the opportunity of obtaining mixed venous oxygen saturation (SvO2 ). This parameter 2). This 

parameter allows for the indirect estimation of hypoxia and peripheral perfusion. Values 
allows for the indirect estimation of hypoxia and peripheral perfusion. Values below 65%
below 65% are considered to be a sign of increased tissue oxygen consumption. This pro‐
are considered to be a sign of increased tissue oxygen consumption. This procedure is
cedure is associated with the risk of severe complications, such as pulmonary artery dis‐
associated with the risk of severe complications, such as pulmonary artery dissection, right
section, right bundle branch block, and catheter‐related infection [2]. Despite its invasive 
bundle branch block, and catheter-related infection [2]. Despite its invasive character and
character and more infrequent application, PAC remains the gold standard of CO meas‐
more infrequent application, PAC remains the gold standard of CO measurement and is a
urement and is a useful tool in monitoring patients in serious and critical conditions [3]. 
useful tool in monitoring patients in serious and critical conditions [3]. The use of PAC is
The use of PAC is recommended in patients with refractory shock and right ventricular 
recommended in patients with refractory shock and right ventricular dysfunction, as well
dysfunction,  as  well 
as patients with severeas shock,
patients  with  severe 
especially in theshock, 
case ofespecially 
associatedin  the respiratory
acute case  of  associated 
distress
acute respiratory distress syndrome [4]. 
syndrome [4].

 
Figure 1. Haemodynamic parameters measured with invasive methods. Global end-diastolic index
Figure 1. Haemodynamic parameters measured with invasive methods. Global end‐diastolic index 
(GEDI); extravascular lung water index (ELWI); cardiac lung water index (ELWI), cardiac function 
(GEDI); extravascular lung water index (ELWI); cardiac lung water index (ELWI), cardiac function
index (CFI), global ejection fraction (GEF); continuous left ventricular contractility (dPmx), Pulmo‐
index (CFI), global ejection fraction (GEF); continuous left ventricular contractility (dPmx), Pulmonary
nary vascular permeability index (PVPI), systemic vascular resistance index (SVRI). 
vascular permeability index (PVPI), systemic vascular resistance index (SVRI).

3. Less Invasive Measurement Methods

3. Less Invasive Measurement Methods 
A slightly less invasive way of obtaining haemodynamic parameters is a method
A slightly less invasive way of obtaining haemodynamic parameters is a method us‐
using PiCCO (Pulse Contour Cardiac Output) technology (Gentige, Göteborg, Sweden).
ing PiCCO (Pulse Contour Cardiac Output) technology (Gentige, Göteborg, Sweden). It 
It combines a pulse wave contour analysis, the transpulmonary thermodilution method,
combines a pulse wave contour analysis, the transpulmonary thermodilution method, as 
as well as a venous blood saturation measurement. Thermodilution calibrates the pulse
well as a venous blood saturation measurement. Thermodilution calibrates the pulse con‐
contour analysis in the individual patient. Two vascular accesses are necessary to perform
tour analysis in the individual patient. Two vascular accesses are necessary to perform the 
the measurements: central venous access and arterial access via the femoral artery or, op-
measurements: central venous access and arterial access via the femoral artery or, option‐
tionally, the axillary or brachial artery. A pulse wave contour analysis allows the marking
ally, the axillary or brachial artery. A pulse wave contour analysis allows the marking of 
of the CO, mean arterial pressure (MAP), stroke volume (SV), stroke volume variation
the CO, mean arterial pressure (MAP), stroke volume (SV), stroke volume variation (SVV), 
(SVV), pulse pressure variation (PPV) and SVR values. On the other hand, using transpul-
pulse pressure variation (PPV) and SVR values. On the other hand, using transpulmonary 
monary thermodilution enables the calculation of the CO, cardiac function (CFI), total
end-diastolic volume, volume of excess extravascular water (EVLW) and complete stroke

 
J. Clin. Med. 2021, 10, 4929 3 of 13

volume. However, oximetry provides several crucial parameters regarding the body’s
oxygen management, including venous blood saturation in the superior vena cava, tissue
oxygen delivery (DO2 ) and oxygen consumption (VO2 ) [5]. Despite its less invasive charac-
ter, when compared with PAC, PiCCO is associated with a risk of iatrogenic complications
connected with establishing vascular access such as pneumothorax, bleeding, catheter-
associated infection or venous thrombosis. Furthermore, the limitations of the pulse wave
contour analysis in the case of arrhythmia or the ventricular function-supporting devices
should also be noted [6].
ProAQT (Gentige, Göteborg, Sweden) is also used for waveform analysis. However,
it does not rely on the thermodilution method and is generally less complex. It can be
easily used for both femoral and radial accesses. Nevertheless, when compared with other
methods, its inaccuracy and inferiority to thermodilution-based CO and SI measurements
is noteworthy [7,8]. Additionally, ProAQT is recognised as inequivalent to the esophageal
Doppler system for haemodynamic monitoring during non-vascular, intermediate-risk
abdominal surgeries [9]. Recently, Hoppe P et al. used this device to determine the
diagnostic accuracy of a mobile application for a snapshot pulse wave analysis in patients
undergoing major abdominal surgeries [10].
Another device allowing a less invasive haemodynamic parameters measurement is
FloTrac™/Vigileo monitor™ (Edwards, Irvine, CA, USA). It is implemented via arterial
access. The FloTrac system enabled the measuring of parameters such as: CO, SV, SVV,
MAP and SVR. They were calculated based on 20 s measurements of SV and pulse pressure,
which allowed for an almost real-time recording. The results obtained using the FloTrac
device in cardiac surgery patients were comparable with those received via an invasive
measurement with PAC [11]. One of the limitations of this device is its inability to precisely
measure CO in extremely obese patients, as well as during liver transplant surgery and
abdominal aortic aneurysm repair surgery [2]. Moreover, the inaccuracy of the FloTrac
device measurements is shown in patients with a low CO and high SVR [12].
Lastly, LiDCO (Lithium dilution cardiac output) technology (LIDCO, London, UK),
which uses pulse wave analysis, is another less invasive technique. The LiDCO system
requires a peripheral artery and central venous catheter (alternatively, a peripheral catheter).
The calibration is conducted using the lithium oxide dilution method and is recommended
every 8 h. Using this device, the following parameters can be recorded: CO, HR, MAP, CI,
SV, SVR, SVRI, SVV, PPV, SPV (systolic blood pressure variations), DO2 and DO2 I (oxygen
delivery) [1].

4. The Continuous, Non-Invasive Measurement of Blood Pressure and

Haemodynamic Parameters
The continuous, non-invasive blood pressure measurement and the monitoring of
haemodynamic parameters are assessed for every heart contraction (beat-to-beat mode).
These procedures are of an entirely non-invasive character, meaning that they do not
disrupt the skin or tissues. Nowadays, the market offers two systems: CNAP (CNSystems
Medizintechnik AG, Graz, Austria) and ClearSight (Edwards, Irvine, CA, USA).
When applying these devices, one should start with entering the patient’s data such
as sex, age, height and weight. The CNAP measurement requires two cuffs: one on the
arm, and the other, a double cuff, on the index and middle finger. A plethysmographic
sensor records the blood volume change in the finger. This allows the maintaining of
the appropriate pressure in the arm’s cuff in order to sustain a consistent blood volume
in the finger. This way, the pressure measured on the arm corresponds to the arterial
blood pressure of every heartbeat, and the monitor shows its high-resolution dynamic
curve in real time. Naturally, every measurement requires a prior device calibration with a
standard oscillometric method (NIPC—Non-Invasive Pulse Co-oximeter) [1,13]. However,
the measurement via ClearSight involves applying a specialized cuff on the patient’s
finger and is based on a non-invasive pressure measurement on the finger’s artery, using a
continuously modified vessel clamp method (so called volume clamp). After eight hours
of constant monitoring on one finger, the cuff should be switched to another finger. The
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and is based on a non‐invasive pressure measurement on the finger’s artery, using a con‐
tinuously modified vessel clamp method (so called volume clamp). After eight hours of 
constant monitoring on one finger, the cuff should be switched to another finger. The total 
total measurement
measurement  time should
time  should  not exceed
not  exceed  72 constant 
72  h  of  h of constant monitoring.
monitoring.  To increase
To  increase  the
the  pa‐
patient’s comfort, two cuffs can be simultaneously put on in order to alternately measure the
tient’s comfort, two cuffs can be simultaneously put on in order to alternately measure the 
parameters between the two fingers. Therefore, an uninterrupted and constant monitoring
parameters between the two fingers. Therefore, an uninterrupted and constant monitor‐
for up to 72 h is possible [6,11].
ing for up to 72 h is possible [6,11]. 
Non-invasive measurements allow the assessment of the following (Figure 2):
Non‐invasive measurements allow the assessment of the following (Figure 2): 

 
Figure 2. Haemodynamic parameters measured with non‐invasive methods and their units. Dia—
Figure 2. Haemodynamic parameters measured with non-invasive methods and their units. Dia—
diastolic arterial pressure (DBP); Sys—systolic arterial pressure (SBP); MAP—mean arterial pres‐
diastolic arterial pressure (DBP); Sys—systolic arterial pressure (SBP); MAP—mean arterial pressure;
sure; PR—pulse rate, heart rate (BMP); CO—cardiac output; CI—cardiac index; SV—stroke volume; 
PR—pulse rate, heart rate (BMP); CO—cardiac output; CI—cardiac index; SV—stroke volume;
SI—stroke  index;  SVR—systemic  vascular  resistance;  SVRI—systemic  vascular  resistance  index; 
SI—stroke index; SVR—systemic vascular resistance; SVRI—systemic vascular resistance index;
PPV—pulse pressure variation; SVV—stroke volume variation. 
PPV—pulse pressure variation; SVV—stroke volume variation.

These values are calculated from the continuously registered pressure curve. Never‐
These values are calculated from the continuously registered pressure curve. Never-
theless, the absolute values are adjusted by the oscillometric measurement. 
theless, the absolute values are adjusted by the oscillometric measurement.

5. Other Non‐Invasive Monitoring Methods 
5. Other Non-Invasive Monitoring Methods
NICCOMO (Medis, Ilmenau, Germany) uses thoracic electrical bioimpedance (TEB) 
NICCOMO (Medis, Ilmenau, Germany) uses thoracic electrical bioimpedance (TEB)
to calculate CO. A low amperage and high frequency electricity is transmitted through 
to calculate CO. A low amperage and high frequency electricity is transmitted through
the chest. During systole, the increase in blood volume in the thorax lowers the resistance 
the chest. During systole, the increase in blood volume in the thorax lowers the resistance
of the passing electricity. The impedance is measured via the electrodes placed along the 
of the passing electricity. The impedance is measured via the electrodes placed along
electricity current. Several other parameters can be measured: CI, SV, SI, SVR and SVRI, 
the electricity current. Several other parameters can be measured: CI, SV, SI, SVR and
SVRI, oxygen
oxygen  delivery
delivery  index index (DOoxygen 
(DO2I),  2 I), oxygen saturation
saturation  (SpO(SpO 2 ), HR,
2),  HR,  SVV,and 
SVV,  andnon‐invasive 
non-invasive
blood pressure (NIBP). Early studies present this technique as an alternative method of
blood pressure (NIBP). Early studies present this technique as an alternative method of 
haemodynamic monitoring, since it is shown to provide similar values to those obtained
haemodynamic monitoring, since it is shown to provide similar values to those obtained 
via the pulmonary thermodilution method [14].
via the pulmonary thermodilution method [14]. 
In patients 
patients supported 
supported by 
by mechanical 
mechanical ventilation, 
ventilation, NICOTM TM (Non-Invasive Cardiac
In    (Non‐Invasive  Cardiac 
Output) can be applied [15,16]. The system allows for the non-invasive measurement
Output) can be applied [15,16]. The system allows for the non‐invasive measurement of 
of CO
CO  and and ventilation
ventilation  parameters.
parameters.  The The device
device  uses uses a partial,
a  partial,  periodic
periodic  carbon
carbon  dioxide
dioxide  re‐
rebreathing technique, causing a CO disturbance. Then, CO is calculated
breathing technique, causing a CO2 disturbance. Then, CO is calculated using the Fick CO
2 using the Fick
2 
CO2 equation. The values of CO, SV, and pulmonary capillary blood flow (PCBF) can be
equation. The values of CO, SV, and pulmonary capillary blood flow (PCBF) can be as‐
assessed. NICO measurements correspond relatively well with those obtained from using
sessed. NICO measurements correspond relatively well with those obtained from using 
the thermodilution method [17].
the thermodilution method [17]. 
Several advantages of the non-invasive methods include: the patient’s safety, simplic-
ity of application, shorter time until intervention, savings on expensive disposable materials
used in invasive methods, and no risk of infection. The relatively limited accessibility
 
J. Clin. Med. 2021, 10, 4929 5 of 13

of these devices could be considered a disadvantage. Using non-invasive measurements

is contraindicated in the following situations: peripheral artery disease, diminished pe-
ripheral blood perfusion (e.g., hypothermia), frequent arrhythmias, vascular implants in
upper limbs, tremor, and no guarantee of reliable readings in haemodynamically unstable
patients [13,18].
A comprehensive comparison of invasive and non-invasive methods is presented in
Table 1.

Table 1. Comparison of invasive and non-invasive methods.

Invasive Methods Non-Invasive Methods

Complexity of application Necessity of complex procedures Simple application
Risk of complications Recognizable/considerable Limited
Possibility of continuous measurement Yes Yes (in some cases)
Need for calibration Yes, depends on device type Yes
Comparable (in some cases, depending on
Accuracy and precision The gold standard
measured parameter and applied criteria)
Time until intervention Longer Shorter
Fit for monitoring critically ill patients Yes No
Fit for intra-operative monitoring Yes Yes
Availability Common Limited, but growing

• Patients who are out of the

• Patients with refractory shock and
critical stage
right ventricular dysfunction
• Patients undergoing elective
• Patients with severe shock and
Indications procedures
acute respiratory distress syndrome
• Patients who are at risk of
• In some cases, to differentiate
haemodynamic compromise or where
cardiogenic pulmonary edema from
the invasive methods put patients at
non-cardiogenic
unnecessary, increased risk

• Tricuspid or pulmonary walve

prosthetisis which can be damage
• Infective endocarditis of the
tricuspid or pulmonary valve
Contradictions
• Severe tricuspid or pulmonic
stenosis
• Right heart mass (tumor or clot)
• Patients with coagulopathy
• Peripheral artery disease
• Diminished peripheral blood
perfusion (ex. hypothermia),
• Frequent arrhythmias
• Vascular implants in upper limbs,
• Tremor

Limitations • life-threatening arrhythmias • Patients critically ill/in shock

• Haemothorax, pneumothorax
• Atrial fibrillation
Complications • Ventricular arrhythmia • These procedures are non-invasive
• Thromboembolic events
• Damage to the valves

6. Assessing Precision and Accuracy

A study involving 21 patients after cardiac surgery, in whom CO was measured up to
two hours after the procedure using PiCCO, FloTrac and LiDCO, in comparison with PAC,
showed LiDCO as the most precise of the less invasive methods [19].
Regarding the non-invasive methods of parameters measurement, two systems are
currently available on the market: CNAP (CNSystems Medizintechnik AG, Graz, Austria)
and ClearSight (Edwards, Irvine, CA, USA). Notably, both are based on the volume-clamp
J. Clin. Med. 2021, 10, 4929 6 of 13

method by Penaza [2]. This method was developed in 1969 by Jana Penaza and involves the
constant regulation of the cuff’s pressure, based on the plethysmographic visual signal [20].
The ClearSight system was compared with invasive methods in 10 trials with a
population of 365 patients. The vast majority of authors showed a good correlation of
CO and blood pressure values obtained by a non-invasive measurement with the ‘gold
standard’; however, these studies did not meet the FDA’s (Food and Drug Administration)
clinical interchangeability criteria [21]. These observations could be explained by the
significant diversity of the studied groups and variances in methodology.
It is worth mentioning that the non-invasive measurements were the most accurate in
patients with high CO and low SVRI values, and the least accurate in patients with low CO
and high SVRI values [22]. The ClearSight, device-mediated cardiac output measurements
showed a moderate correlation with the results measured in echocardiography [23].
Conversely, SBP, DBP and MAP measurements made by a CNAP device in a study of
2019, were considered as comparable, obtaining invasive measurements and meeting the
criteria for their interchangeable use in stable patients remaining in an intensive care unit
after cardiac surgery [24]. Similar results regarding SBP, DBP and MAP measurements were
published in a study comparing both methods in patients undergoing elective surgical pro-
cedures [25–28]. The data regarding the accuracy of CO measurements by CNAP is limited.
Wagner et al. concluded that the continuous, noninvasive determination of cardiac output
is feasible in critically ill individuals [29]. The measurements by CNAP in comparison
with those obtained invasively using transpulmonary thermodilution (PiCCO) showed a
percentage error of 25%, recognized as an acceptable agreement between the investigated
techniques. In another study, CNAP-derived cardiac index measurements were recognized
as noninterchangeable with those obtained using 3-dimensional images [30]. However, the
high systemic vascular resistance index in patients undergoing abdominal aortic aneurysm
surgery may partially account for the observed inaccuracies.
However, a meta-analysis from 2014 of 28 studies, with 919 participants, involv-
ing various non-invasive haemodynamic monitoring devices showed inaccuracy and a
lack of precision in SBP, DBP and MAP measurements, when compared with invasive
monitoring [31]. In response to the mentioned meta-analysis, there were other research
discrepancies in implementing the precision and accuracy criteria of the Association for
the Advancement of Medical Instrumentation, in relation to blood pressure measurements
via non-invasive devices and in a population not fully matching the set assumptions [32].
These comments express the need for establishing new standards regarding the evaluation
of non-invasive, haemodynamic parameters measurement methods.

7. Non-Invasive Haemodynamic Monitoring—Examples of Clinical Application

When the first devices for non-invasive haemodynamic monitoring entered the mar-
ket, the research on their clinical application was initiated. Intensive care units and anes-
thesiologists became the main beneficiaries of the new devices, as they used them for
intraoperative cardiovascular monitoring. Recently, TEB provided additional information
regarding the haemodynamic alternations resulting from the induction of general anaes-
thesia [33]. Nonetheless, Hong J Y et al. evaluated the effect of preoperative epidural
analgesia on intraoperative cardiovascular parameters during laparoscopic hysterectomy
using NICO [34].
Furthermore, non-invasive monitoring enabled the observation of characteristic devi-
ations in haemodynamic parameters in particular groups. A noticeable difference between
SBP and DBP, as well as a high acceleration on the pulse wave sigmograph, were the
characteristic features of aortic regurgitation (Figure 3A). In cirrhotic patients, we noticed a
low peripheral vascular resistance and an increased cardiac output, which were present
at rest, as shown in Figure 3B,C. This stems from a systemic vascular vasodilatation and
blood redistribution into the visceral vessels. Other departments have also benefited from
the technology development.

J. Clin. Med. 2021, 10, 4929
viations in haemodynamic parameters in particular groups. A noticeable difference be‐
tween SBP and DBP, as well as a high acceleration on the pulse wave sigmograph, were 
the characteristic features of aortic regurgitation (Figure 3A). In cirrhotic patients, we no‐
ticed a low peripheral vascular resistance and an increased cardiac output, which were 
present at rest, as shown in Figure 3B,C. This stems from a systemic vascular vasodilata‐7 of 13
tion and blood redistribution into the visceral vessels. Other departments have also bene‐
fited from the technology development. 

 
Figure 3.  Record  of measured  haemodynamic  parameters in  patients  (example). (A)  A  66‐year‐old patient  with severe 
Figure 3. Record of measured haemodynamic parameters in patients (example). (A) A 66-year-old patient with severe
aortic regurgitation was admitted to cardiology department to assess the width and qualification of the ascending aorta 
aortic regurgitation was admitted to cardiology department to assess the width and qualification of the ascending aorta for
for surgical valve treatment. Echocardiography demonstrated normal heart size, distended ascending aorta, and aortic 
surgical valve treatment. Echocardiography demonstrated normal heart size, distended ascending aorta, and aortic bulb.
bulb. Severe aortic regurgitation. EF 59%. Analysis of the pulse wave shown in the diagram reveals a well‐defined dicrotic 
Severe aortic regurgitation. EF 59%. Analysis of the pulse wave shown in the diagram reveals a well-defined dicrotic notch
notch that is characteristic of aortic regurgitation. (B) A 55‐year‐old patient with restrictive cardiomyopathy caused by 
that is characteristic of aortic regurgitation. (B) A 55-year-old patient with restrictive cardiomyopathy caused by genetically
genetically determined transthyretin amyloidosis presenting to the hospital for re‐evaluation of indications of combined 
determined transthyretin amyloidosis presenting to the hospital for re-evaluation of indications of combined liver and heart
liver and heart transplant. This disease is characterized by left ventricular diastolic dysfunction. The figure shows charac‐
teristic low cardiac output and stroke volume with high systemic vascular resistance. (C) A 46‐year‐old male with mixed 
transplant. This disease is characterized by left ventricular diastolic dysfunction. The figure shows characteristic low cardiac
output and stroke volume with high systemic vascular resistance. (C) A 46-year-old male with mixed HBV/ALD aetiology
cirrhosis, complicated with hepatic encephalopathy and ascites, with a history of portal hypertension, oesophageal varices
  bleeding, arterial hypertension, heart failure, asthma, and type 2 diabetes. Qualified for liver transplant surgery. This
example perfectly shows the features of hyperdynamic circulation characteristic of hepatic cardiomyopathy: low systemic
vascular resistance, high cardiac output, high stroke volume and tachycardia. Sys—systolic blood pressure; Dia—diastolic
blood pressure; MAP—mean arterial pressure, CO—cardiac output; SV—stroke volume; SVR—systemic vascular resistance;
PPV—pulse pressure variation; CI—cardiac index; SI—stroke volume index; SVRI—systemic vascular resistance index;
SVV—stroke volume variation.
Although some of the new techniques seem promising for the paediatric population,
data regarding this group of patients remains limited [35,36].
J. Clin. Med. 2021, 10, 4929 8 of 13

8. Non-Invasive Haemodynamic Monitoring and Non-Cardiac Surgeries

In surgical patients, haemodynamic instability can occur during the perioperative
period, which is caused by the shift in the volume of the intravascular fluid, anaesthetics,
and surgical intervention. Therefore, the fundamental aim of anaesthetic monitoring during
surgical procedures is to control the haemodynamic parameters. The good credibility and
equivalence of the haemodynamic measurements (SBP, DBP, MAP, PPV) obtained in the
operating theatre via a non-invasive method, when compared to invasive methods, is
noteworthy [37–39].
Using a constant, non-invasive arterial blood pressure measurement in patients with
ClearSight under general anaesthesia undergoing non-cardiac surgeries decreased the
hypotension time by half [40]. These results remain consistent with another study, in which
a constant ClearSight monitoring contributed to an earlier diagnosis of hypotension and
introduced an effective treatment compared to the standard oscillometric measurement in
patients during and after orthopaedic surgery [41]. It is worth stressing, that even a short
intraoperative episode of hypotension can greatly affect organ functioning and subsequent
complications. In extreme cases, a critical decrease in blood pressure may lead to a sudden
cardiac arrest.
In another study, with patients undergoing complete hip or knee joint replacement
surgeries, the fluid therapy scheme in the studied group was based on non-invasive
haemodynamic monitoring, especially the pulse pressure variation (PPV) and, in the control
group, fluid therapy was based on a standard oscillometric blood pressure measurement,
every 5 min. The intraoperative fluid therapy under CNAP control resulted in a decreased
number of postoperative complications (83% in the control vs. 55% in the studied group)
and necessary blood products transfusion (75% patients in the control vs. 38% in the
studied group). Moreover, the number of intraoperative hypotension episodes decreased
by 33% in the studied group with a lower postoperative mean arterial blood pressure
(MAP = 103 mmHg) compared to the control group (MAP = 118 mmHg) [42]. CNAP
monitor was also used for the early detection of rapid decreases in blood pressure, occurring
during the c-section in patients under subarachnoid anaesthesia [43,44]. Studies stress
the usefulness of PPV monitoring in patients under general anaesthesia, in providing
haemodynamic stability and showing PPV as an accurate parameter of the haemodynamic
response to fluid therapy [45,46].
Furthermore, a high correlation of non-invasive PPV measurements, when compared
with invasive methods, is shown [47,48]. These results suggest that non-invasive haemody-
namic monitoring is a valuable element of intraoperative monitoring; however, its correla-
tion with patients’ prognoses requires further research [41]. There are limited available data
regarding the clinical implications of using the NICO system in non-cardiac patients [49].
Moreover, there is no direct comparison of clinical applications in both non-invasive
monitoring systems, CNAP and ClearSight.

9. Non-Invasive Haemodynamic Monitoring and Cardiosurgery and

Interventional Cardiology
Another important group of patients, in whom haemodynamic monitoring is essential,
are patients undergoing cardiosurgical procedures. In haemodynamically stable patients
undergoing coronary artery bypass grafting (CABG), postoperative cardiac output values
measured by a non-invasive technique were comparable to those measured via an invasive
PiCCO method [50,51] and those calculated based on a transthoracic echocardiography [52].
Lorsomradee S. et al., in a group of 36 patients, compared the CO values acquired via a
non-invasive and an invasive method and obtained similar results [50]. Similar conclusions
were drawn in Bronch O. et al.’s study, where, in 40 patients undergoing CABG, the
CO values were measured while inducing a general anaesthesia until discharge from the
intensive care unit [51]. However, these results were not reflected in other studies, in which
non-invasive cardiac output measurements after cardiac surgery, despite a good trend
of real-time CO changes, did not meet the equivalence criteria of both methods, when
J. Clin. Med. 2021, 10, 4929 9 of 13

compared with the invasive methods [53,54]. Noteworthy, blood pressure measurements
in these studies were credible, comparable and met the equivalence criteria with regard to
both invasive methods.
In a study of 33 patients with severe aortic stenosis undergoing percutaneous aortic
valve implantation (TAVI) via transfemoral access, no significant differences were found
in the accuracy of blood pressure measurements using a non-invasive method (CNAP)
and an invasive (intra-arterial) method. Furthermore, the non-invasive blood pressure
measurement during fast heart stimulation, accurately and immediately showed signif-
icant alternations in the haemodynamic parameters [55]. Similar results in accuracy of
blood pressure and cardiac output were obtained in two studies in which the ClearSight
system was applied and compared to the invasive monitoring in patients with aortic and
mitral valve replacement [56,57]. Another study found that an agreement between NICO
and invasive hemodynamic monitoring was clinically acceptable, but had a tendency to
underestimate CO compared to the termodilution method [49].
Apart from these findings, there are very limited data showing any clinical benefits,
including patient outcomes and cost effectiveness, from using non-invasive hemody-
namic monitoring.

10. Non-Invasive Haemodynamic Monitoring and Intensive Care

Haemodynamic monitoring is essential for patients in critical condition and for those
requiring intensive care. The studies regarding the utility of non-invasive haemodynamic
monitoring methods in this population gave contradictory conclusions. The research
involving 40 intensive care unit patients showed an accuracy of non-invasive monitoring
blood pressure measurements when compared to the invasive measurements [58]. Another
study on 55 intensive therapy patients proved the precision of non-invasive DBP and MAP
measurements via CNAP. These values were similar to those acquired via an invasive
method. However, the SBP measurements were less precise and accurate when compared
with the values from the intra-arterial catheter [59]. By contrast, smaller studies involving
intensive therapy patients questioned the accuracy of non-invasive measurements with
both CNAP and ClearSight and their application in the studied population [22,60,61]. It
is worth mentioning that the studied groups consisted of patients with a broad spectrum
of underlying diseases, contributing to their serious conditions. Again, there was a small
number of studies regarding the NICO system application in intensive care units with
one study showing a moderate correlation with invasive methods, but which was still
applicable to patients not breathing spontaneously [62].
Regarding cardiology, non-invasive haemodynamic monitoring techniques were
tested on a group of 84 heart failure patients, mainly NYHA III and IV; the mean ejection
fraction was 27%. The non-invasive measurement of cardiac output compared to the
thermodilution method was revealed to be overestimating and not recommended for this
population [63]. Despite being disappointing, this result remains in line with observations
from other studies, in which non-invasive haemodynamic monitoring methods showed
less precise measurements in the case of decreased cardiac output and increased peripheral
vascular resistance [22]. It might also partially explain the inaccuracy of measurements for
patients in critical conditions that remain in intensive care units.
The clinical utility of NICCOMO in intensive care unit patients requires further
investigation as the data regarding this matter are limited [64].

11. Summary
Considering the complexity of procedures and the possible severe complications
associated with invasive haemodynamic monitoring, alternative solutions are being widely
explored. Non-invasive methods were found to be successful in numerous areas. In
surgical patients, they were used for intraoperative cardiovascular monitoring and the
early detection of haemodynamic alternations, as well as for adjusting the fluid therapy.
Furthermore, a reduction in postsurgical complications was noted. These findings come
J. Clin. Med. 2021, 10, 4929 10 of 13

from various hospital wards, other than the cardiac department, including anaesthesiology,
orthopaedic surgery and gynaecology wards. Even though a wide range of parameters
can be obtained, in some cases an invasive approach is necessary. This includes not only
critically ill patients, but also those in shock or suffering from heart failure. Nevertheless,
in some patients, the implementation of the non-invasive methods might be the missing
link between an invasive approach, such as thermodilution, and a simple oscillometric
cuff measurement. Hence, patients with non-cardiac conditions which severely alter
their hemodynamic state, e.g., cirrhosis and chronic kidney disease, should be the next
potential group that could benefit from non-invasive hemodynamic monitoring and require
further investigation.
The data regarding monitoring patients in intensive care units, using new technologies,
remain contradictory and require more studies. Moreover, it is crucial to further investigate
how these non-invasive techniques could influence the therapeutic decision-making process
and patients’ prognoses, as well as analyse the economic aspects of these interventions.
In addition, other potential clinical practice applications should also be widely explored.
Furthermore, a substantial need for establishing and standardizing the evaluation criteria
of non-invasive haemodynamic monitoring devices is noted. The current criteria were
initially applied only to oscillometric temporary measurements. Therefore, they seem to not
be applicable in evaluating the constant, non-invasive measurements of the haemodynamic
parameters [2,32].
Finally, the approach to choose the right method should always be individually
tailored to the patient and still recognize the contradictions, as well as the limitations.

Author Contributions: Conceptualization, all authors. methodology, A.B.-P., M.K., R.G.; literature
investigation, A.B.-P., M.K., M.B.; resources, A.B.-P., M.K., M.B.; writing—original draft preparation,
A.B.-P., M.K., M.B.; writing—review and editing, R.G., M.G.; visualization, all authors; supervision,
R.G., M.G.; funding acquisition, A.B.-P., M.K., R.G. All authors have read and agreed to the published
version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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